Transcript Electronic Medical Records / Benefits to Clinicians

Electronic
Medical
Record
March 27, 2009
Curtis L. Whitehair, MD, FAAPMR
Board Certified Physiatrist
Physical Medicine & Rehabilitation
Fellow American Academy of Physical
Medicine & Rehabilitation
• President – Maryland Society of PM&R
National Rehabilitation Hospital, Washington,
DC
 Medical Director – Outpatient Center for
Orthopedic Rehabilitation
 Medical Director – Oncology Rehabilitation
Program, NRH/NRH Regional Rehab
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Shepherd University, Shepherdstown WV
◦ Major
 Business Administration
 Information Systems & Computer Programming
◦ Minor
 Communications
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CASE Consultant – Datatel, Inc.
◦ 3 Books
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ETK: Introduction to Screen Processing
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ETK: Introduction to Batch and Report Writing
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Managing Custom Source
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Ross University School of
Medicine, NY/Dominica
Internship – Family Medicine at
Medical College of Virginia
(VCU), Richmond VA
Residency – Physical Medicine &
Rehabilitation at NRH/GTUH,
Washington, DC
According to the IOM, an EHR system has several key
capabilities:
◦ It’s a longitudinal collection of electronic health
information for and about persons.
◦ It provides immediate electronic access to person- and
population-level information by authorized users.
◦ It provides knowledge and decision-support systems
that enhance the quality, safety, and efficiency of patient
care.
◦ It supports efficient processes for health care delivery.
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Physicians spend 38% of their time writing chart notes.
35-39% of total hospital operating cost are spent on
patient and provider communication activates.
Medical records could not be located 30% of the time
when needed.
Once found the volume of information in them was
often so large that it became unmanageable.
It was shown that simply organizing information flow
sheets accelerated retrieval of needed data at least 4fold.
Top 10 Causes of Death in 1998
1 Heart Disease
724,269
2 Cancer
538,947
3 Stroke
158,060
4 Lung Disease
114,381
5 Medical Errors
98,000
6 Pneumonia
94,828
7 Diabetes
64,574
8 Motor Vehicle Accident
41,826
9 Suicide
29,264
10 Kidney Disease
26,295
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Stage III, IV pressure ulcers
Fall or trauma resulting in serious injury
Vascular catheter-associated infection
Catheter-associated urinary tract infection
Foreign object retained after surgery
Certain surgical site infections
Air embolism
Blood incompatibility
Certain manifestations of poor blood sugar
control
Certain deep vein thromboses or pulmonary
embolisms
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> 50% of all healthcare
expenditures in the US is
on ambulatory care (rate of
increase is greater for
outpatient than inpatient
services)
~80% of the nearly 1 billion
annual outpatient visits
take place in practices of
10 or fewer clinicians
~50% in practices with
fewer than 5 clinicians
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Practices between 1-9 physicians account for
88% of physicians
In practices larger than 9 physicians, adoption
rates are significantly higher
Practice Size
% Using EHR
% Distribution of Physicians in
Sample (n=3,360)
1
13.0
35.3
2-4
16.2
39.9
5-9
19.9
12.8
10-19
28.7
7.1
20-above
38.9
4.9
(# of Physicians)
88%
Source: Burt and Sisk, 2005
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Reactive episodic visits
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“Top-of-mind” decisions
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Paper-based ad hoc
prescribing
Non-interactive
documentation
No news = good news
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Reactive episodic visits
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Reactive and proactive care
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“Top-of-mind” decisions
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Embedded CDSS/guidelines
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Paper-based ad hoc
prescribing
Non-interactive
documentation
No news = good news
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Knowledge based Medication
Management (eRx)
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Interactive documentation
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Orders loop management
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While promoting medical quality and E/M
compliance, in 15 minutes a provider must be
able to:
◦ Perform and complete documentation of a medically
indicated, audit-proof, level 4 or level 5 patient visit
 with individualized narrative information in all
appropriate areas of the medical record
 including completion of counseling the patient
 ordering test
 ordering treatment
 charge entry
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A value configuration describes how value is
created in a company for its customers. It
shows how the most important primary and
secondary activates function to create value
for customers.
It represents the way a particular organization
conducts business.
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The development of an Electronic Medical
Record is not merely the construction of an IT
system but a continual organizational
improvement process aimed at bringing the
healthcare organization to a higher
achievement level through people, processes
and technology.
The process changes with the users needs
and requirements as they learn as well as
technology and knowledge evolves.
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As care processes become more dependent on IT clinical
expectations of availability increasses.
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Clinicians are used to high availability technical infrastructures.
Benefits of Implementing EMRs
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Improve Quality Care
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Avoid Adverse Drug Events
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Improve Quality Measures
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Enhance Patient Safety
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Improve Operational Efficiencies
and Reallocate Staff
Increase Reimbursements
Decreased cost
DesRoches, et. al., NEJM, July3, 2008
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Simultaneous 24/7 health record availability
◦ Emergency/On Call physician
Improved chronic disease management
◦ Prompts doctors and nurses whenever health
maintenance services are past due.
◦ Prompts doctors and nurses to perform chronic
disease management services and identifies when
parameters are not met.
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Improved continuity of care and preventative
care among different providers
Record is legible and timely
Record is more consistent across different
providers
CPOE
eRX
eMAR
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Standardize and integrate data capture for quality
measurement into the normal documentation of
care within the ambulatory EMR.
Reporting abilities of flow and process allow better
understanding of process and procedures.
◦ Data can flow into PI modules/software with import and export
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Implementation of an automated system for data
extraction including valid, reliable reports that
provide actionable insight for the measurement,
analysis and improvement of care.
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Increased safety in prescribing due to drug
interactions and allergy alerts.
Ease of accessing patient prescription
information in case of drug recall.
More efficient phone triage due to immediate
access to patient records.
Consultant Reports and legible and timely.
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Increased staff job satisfaction
◦ Reduced staff stress related to failed searches for
paper records
◦ Improved communication among staff
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Staff to physician ratio decreased below
national ratio average
◦ FTE decrease 1 – 2.5 per physician.
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Physical Plan reduction
◦ Convert filing area to 3 exam rooms.
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Better E/M documentation enhances provider confidence to
code and bill appropriately for services rendered
◦ It is common to down-code for fear of the audit or denials.
◦ Service Notes are more defensible from a billing perspective
Transcription cost saved
Discounts from malpractice insurer
◦ The malpractice insurer believes EMR greatly reduces
potential of drug errors / misunderstood notes
Improve charge capture
◦ Reduction in delays in billing activities
◦ Reduction in payer denials
Basic EHR
On line chart with:
- Clinical note
documentation
- Results viewing
($18,200)
Net Cost
Intermediate EHR
Basic plus:
- Electronic
prescribing with:
- Adverse drug
prevention capability
- Alternative drug
suggestion
$44,600
Net Benefit
Advanced EHR
Intermediate plus:
- Lab order entry with testing
guidance
- Radiology order entry with
test guidance
- Electronic Charge Capture
$86,400
Net Benefit
Valley View Case Study
Goshen, NY
520 Beds
4 Buildings
15 Units
– Sub-Acute Rehabilitation
– Long Term
– Dementia/Alzheimer's
– Palliative Care
Over 600 Employees
Valley View’s Business Issues
Business Issues
Lost Revenue
Medicare billing inefficiencies
Inaccurate data capture
Increasing Costs
Formulary non-compliance was resulting in
escalating drug costs
Less time on resident
care due to
inefficiencies
Clinician and staff
frustration high
Inefficient Work Flow
Renewal process lengthy and error prone
Difficult to manage off-hour admissions
Cumbersome communication within facility
Nursing staff mired in paperwork
Resident Safety Concerns
Difficult to manage quality with paper and
retrospective MDS data
Incomplete or ambiguous orders
DUR alerts missed or late
In danger of losing
reference lab
Inefficiencies resulted
in an underlying
concern for
resident safety
Valley View’s Return on Investment
Business Process
Automated
Direct Financial
Benefit
Medication order renewal
process
Formulary updates,
communication and control
Facility communication and
order data entry (telephone,
ADT, etc.)
Pharmacy communication and
order data entry
Resident identification, alert
and room/bed assignment
* Through attrition
5 FTE Staff Reduction*
Medication savings
Renewal efficiencies
Efficiencies in
formulary training
Consultation forms
Medicare billing
improvement
Lab billing
improvement
Additional
Efficiencies
92% reduction in adverse
drug events (from avg. of
$ 250,000
2.81 per month to .23 per
$ 262,000
month)
$ 120,000
$
8,000 9% additional time for over
200 employees (700 hours
per week) to focus on
$ 20,000
direct resident care
$ 15,000
$
10,000
Reporting (resident safety,
quality indicators, DUR,
shift productivity, census)
Compliance with State,
Federal and accreditation
audits, surveys and ad hoc
requests
Questions ?